Federal inspection record · CMS data as of October 1, 2026
Lake Village Nursing And Rehabilitation Center
169 Lake Park Rd, Lewisville, TX · (972) 436-7571
- Certified beds
- 112
- Residents per day
- 78
- Ownership
- For-Profit
- Chain
- The Ensign Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- January 4, 1996
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Texas.
-
Staffing
★★★★★−1 star
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Texas homes
Lake Village Nursing And Rehabilitation Center carries 98 inspection points. That is fewer than 37% of Texas's 1,166 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Texas: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–26 pts
- 4★ 26–51 pts
- 3★ 51–85 pts
- 2★ 85–145.75 pts
- 1★ over 145.75 pts
Bars show every rated home in Texas by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
33 health citations on record since 2024. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
K
Provide and implement an infection prevention and control program.
Everything else, by area of care
Quality of Life and Care7E
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Resident Rights7E
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Keep residents' personal and medical records private and confidential.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- E
Reasonably accommodate the needs and preferences of each resident.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Pharmacy Service4D
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Resident Assessment and Care Planning4D
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Nutrition and Dietary3E
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control3E
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
Administration1F
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Environmental1E
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Nursing and Physician Services1F
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Freedom from Abuse, Neglect, and Exploitation1D
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspection history
2026-05-05
10 health deficiencies · 2 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2025-03-06
11 health deficiencies · 2 fire-safety deficiencies
Top issue: Resident Rights (3 deficiencies)
2024-01-26
12 health deficiencies · 3 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 2 h 59 min of nursing staff time a day, 21 min of it from a registered nurse.
This home
2 h 59 min
Texas average
3 h 25 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$24,585 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2024-01-26 | Fine | $24,585 |
| 2024-01-26 | Payment Denial · 8 day denial | $0 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.7 pts worse | 2.7 | 2.0 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.9 pts better | 1.1 | 2.0 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine2.5 pts better | 98.9% | 96.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine3 pts better | 100.0% | 97.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.8 pts better | 1.4% | 3.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms2.3 pts better | 0.0% | 2.3% | 13.5% |
| Percentage of long-stay residents who lose too much weight2.5 pts better | 0.4% | 2.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.6 pts worse | 18.4% | 17.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication0.9 pts worse | 10.7% | 9.8% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened6.4 pts worse | 19.3% | 12.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased4.7 pts worse | 20.5% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.3 pts better | 0.0% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.3 pts worse | 1.1% | 0.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence4.3 pts worse | 16.8% | 12.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.9 pts better | 1.8% | 3.7% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine8.2 pts better | 96.9% | 88.7% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit7.5 pts better | 4.7% | 12.2% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.5 pts worse | 1.9% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine2.1 pts worse | 83.3% | 85.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission2.6 pts better | 22.9% | 25.5% | 23.4% |
·
Who owns and runs it
17 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Eastland Memorial Hospital District | 5% Or Greater Direct Ownership Interest · Organization | 100% | 34 facilities |
| Burnam, Soon | Corporate Officer · Individual | 0% | 353 facilities |
| Caretrust Gp LLC | Adp Of The SNF · Organization | 0% | 95 facilities |
| Caretrust Reit Inc | Adp Of The SNF · Organization | 0% | 102 facilities |
| Ctr Partnership LP | Adp Of The SNF · Organization | 0% | 104 facilities |
| Ensign Services Inc | Adp Of The SNF · Organization | 0% | 299 facilities |
| Grand Villa Phx, Inc. | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Grand Villa Phx, Inc. | Adp Of The SNF · Organization | 0% | 1 facilities |
| Hernandez, Miguel | Managing Control - Governing Body · Individual | 0% | 4 facilities |
| Hernandez, Miguel | Operational/Managerial Control · Individual | 0% | 4 facilities |
| Hernandez, Miguel | Adp Of The SNF · Individual | 0% | 4 facilities |
| Keetch, Chad | Corporate Officer · Individual | 0% | 301 facilities |
| Mall, Allen | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Mall, Allen | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Mall, Allen | Adp Of The SNF · Individual | 0% | 1 facilities |
| Taylor, Stephen | Corporate Officer · Individual | 0% | 22 facilities |
| Verde Villa Holdings LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
·
Fire safety
7 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke4F
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- F
Provide properly protected cooking facilities.
- F
Inspect, test, and maintain automatic sprinkler systems.
Gas, Vacuum, and Electrical Systems2F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Services1F
- F
Have properly installed electrical wiring and gas equipment.
·
Other homes nearby
-
Rambling Oaks Courtyard Extensive Care Community
Highland Village, TX
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 59 min
- Fines
- $31,265
-
Hollymead
Flower Mound, TX · Cantex Continuing Care
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 3 h 43 min
- Fines
- $9,110
-
Cross Timbers Rehabilitation and Healthcare Center
Flower Mound, TX · Nexion Health
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 43 min
- Fines
- $8,281